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Health Care Access Maryland and St. Agnes Hospital

  • Health Care Access Maryland and St. Agnes Hospital

  • Concierge Care Transition Support

Goal:

Maryland has one of the highest readmission rates in the country. Our program addresses the 5 most prevalent conditions and procedures that have resulted in readmissions in the Baltimore community.

Project Description:

HealthCare Access Maryland (HCAM) is dedicated to ensuring that all Marylanders have equal access to health care and services. Each year, HCAM serves more than 125,000 Marylanders, including children, pregnant women, parents, childless adults, immigrants, homeless people, youth in foster care, people with substance use disorders, individuals recently released from jail, and many others.

HCAM’s pilot program focuses on creating post-discharge patient-centered “health neighborhoods” that addresses both medical and healthcare related needs by engaging discharged patients with health tips and reminders, targeted chronic condition education, and local outpatient healthcare resources, to help ensure the best possible outcomes and to reduce readmissions.

Solution:

Using the GoMo Health Concierge Care® platform and select, condition-specific health content, St. Agnes Hospital looks to reduce readmissions through patient-direct follow up, education and outreach. Discharge Nurses working within the St Agnes Healthcare system enrolls patients at point of discharge, using an online HRA survey developed specifically to support patient health post discharge. Coordination of care in these new patient-centered “Health Neighborhoods” utilized in this pilot, will enable St. Agnes Care Coordinators to motivate, oversee, remind and supervise patients for up to three (3) months post discharge.

GoMo Health has deployed this Concierge Care® Readmission Reduction program for HCAM, consisting primarily of middle age adults having undergone specific procedures and/or with chronic conditions, relating to: Hypertension/Heart Disease, Diabetes, Asthma, and COPD. GoMo Health’s Concierge Care® platform is utilized to enable the St. Agnes Healthcare System to engage their high-risk patients with a post-discharge protocol that immerses them in a health-oriented “neighborhood of care”, upon discharge. Using a custom-developed engagement protocol created specifically for this pilot, St. Agnes Discharge Nurses will integrate program enrollment into their discharge procedures.

The Concierge Care® platform will integrate program-aligned condition-specific multimedia educational content, care regimens, reminders, and available local resources with pre-determined mobile engagement protocols, that may include message stratification (by condition and/or co-morbidities) and HIPAA compliant 2-way live text chat. The platform infrastructure supports the development of program stratification to deliver relevant content to each individual patient, based survey answers at point of enrollment.

 

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